Recipient

Elmley Prison

First report 27 Apr 2018•Latest report 9 Feb 2026

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Elmley Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

9 Feb2026
Kent and Medway
Concerns raised2
1. Lack of prison officer training in acute behavioural disturbance (ABD)
2. Failure of prison officers to recognise ABD as a medical emergency
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Josh Yemi TARRANT · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine toxicity following a lengthy and challenging restraint while experiencing an acute behavioural disturbance. The principal concerns were that the disturbance was not recognised by healthcare staff, that an ambulance was not called at the earliest appropriate opportunity, and that prison and healthcare staff lacked training in acute behavioural disturbance. The inquest jury found that the failure to provide sufficient medical treatment probably significantly contributed to his death and that his death was contributed to by neglect.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of prison officer training in acute behavioural disturbance (ABD)
Wider context from the report
“HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then. None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD. Dr ████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”). Dr ████████ also stated that: (1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes; (2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments; (3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived. I am concerned that: (a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600). (b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure of prison officers to recognise ABD as a medical emergency
Wider context from the report
“HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then. None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD. Dr ████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”). Dr ████████ also stated that: (1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes; (2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments; (3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived. I am concerned that: (a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600). (b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future. ”
Open source report
29 Jul2025
Kent and Medway
Concerns raised3
1. Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
2. Failure to establish prison healthcare capability to replicate ambulance-service emergency skills
3. Lack of cross-party dialogue and learning from serious medical emergencies
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Azroy Dawes-Clarke · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Azroy Dawes-Clarke died in hospital on 10 November 2021 after an episode of self-strangulation in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrest during conveyance to hospital. The substantive concerns included disproportionate and prolonged restraint, delays in obtaining healthcare assistance and starting CPR, inadequate communication, and uncertainty about responsibility for acute medical emergencies in custodial settings.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings
Wider context from the report
“(2) Despite the severity of the incident which occurred in this case, it appeared that there still remains confusion as to which public body would have primary in an acute medical emergency in a custodial setting. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to establish prison healthcare capability to replicate ambulance-service emergency skills
Wider context from the report
“(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved. Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence. During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting. One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service). ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of cross-party dialogue and learning from serious medical emergencies
Wider context from the report
“(1) Despite the severity of the incident which occurred in this case, there had been little (if any) dialogue between leaders of the various parties involved. Formal complaint processes, safeguarding processes and risk reporting mechanisms had been used, but there was no discussion about how to learn from this specific case or how to avoid a reoccurrence. During prevention of future death evidence, responses were inconsistent as to how to avoid other difficulties during a major medical emergency in a prison setting. One suggestion made was that paramedics may not enter custodial settings in future but it was unclear how prison healthcare could replicate the skills had by the ambulance service (in particular, in the use of intraosseous access during initial resuscitation, or the skill sets of a critical care paramedic or an advance trauma team which may be delivered by a helicopter emergency medical service). ”
Open source report
25 May2021
Mid Kent and Medway
Concerns raised4
1. Failure to routinely brief Prison Officers about prisoners’ previous significant self-harm in custody
2. Lack of direct and immediate access to telephone, listening and chaplaincy support for prisoners
3. Unclear threshold for informing prison staff about significant self-harm risk
1. Failure to routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

James Devenny · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

James Devenny died in his cell at HMP Elmley on 2 September 2019, having been found hanging from a light fitting using a bedsheet ligature. The jury identified concerns including staff not being aware of his previous self-harm history, the absence of a medical assessment before his separation from other prisoners, an inappropriate response to mental health referrals, and inadequate access to phones and support services. The report also records concerns about prison officers not being routinely briefed about prisoners’ previous significant self-harm and related patterns of thoughts, feelings, events and behaviours.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to routinely brief Prison Officers about prisoners’ previous significant self-harm in custody
Wider context from the report
“(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of direct and immediate access to telephone, listening and chaplaincy support for prisoners
Wider context from the report
“(1) In the absence of telephones which are installed directly into the cell, there is no direct means for a prisoner to contact the Samaritans. In the event that a prisoner does not have access to a telephone they are reliant on staff to convey them to a telephone so they may call. There is a particular difficulty in respect of prisoners who are deemed to pose a risk of violence and who may not be able to immediately access a telephone, a listener or a member of Chaplaincy. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Unclear threshold for informing prison staff about significant self-harm risk
Wider context from the report
“(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm
Wider context from the report
“(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm. ”
Open source report
27 Apr2018
Mid Kent and Medway
Concerns raised1
1. Failure to prevent access to razor blades
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

PAUL DAVID ANTHONY JAMES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

PAUL DAVID ANTHONY JAMES died in HMP Elmley on 20 December 2016 after inflicting an incised wound to his abdomen with a razor blade. The report identifies concern that he was given access to razor blades despite his history of serious self-harm and suicidal statements.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Elmley Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to prevent access to razor blades
Wider context from the report
“That Mr James was given access to razor blades in all the circumstances. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Lack of prison officer training in acute behavioural disturbance (ABD)

Failure of prison officers to recognise ABD as a medical emergency

Concerns raised3

Confusion over which public body has primary responsibility for acute medical emergencies in custodial settings

Failure to establish prison healthcare capability to replicate ambulance-service emergency skills

Lack of cross-party dialogue and learning from serious medical emergencies

Concerns raised4

Failure to routinely brief Prison Officers about prisoners’ previous significant self-harm in custody

Lack of direct and immediate access to telephone, listening and chaplaincy support for prisoners

Unclear threshold for informing prison staff about significant self-harm risk

Failure to routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm

Concerns raised1

Failure to prevent access to razor blades